TODAY’S DOSE OF HONESTY

Are HRT creams a good option for YOU?

This weekend, I met three great women from New Hampshire who asked me lots of questions they had about perimenopause and menopause—hair and hormones in general. They inspired me to cover a specific form of hormone replacement therapy (HRT) in this week’s newsletter. The topic of hormones is one we’ll be discussing at great length in TODAY’S AJENDA because there is so much myth, misconception, misunderstanding, and outright confusion surrounding the use of hormones during and after menopause. Today, my Dose of Honesty is about HRT in cream form.  

Let's say you've decided you want to start taking HRT in some form. (I do!) Your next decision involves what form to take. There are pills (oral), transdermal patches and creams (absorbed through the skin), vaginal inserts and creams, and injectable pellets that sit just beneath the skin’s surface. They all have different pros and cons, but there are basics that apply to each. Today, we’ll talk about transdermal creams. 

An important feature of creams is that, as with the patch, the hormones are absorbed into the skin and then into the bloodstream. Since they aren’t orally ingested, they bypass liver metabolism and do not activate the body’s clotting system to the same extent as a swallowed, pill-form hormone does. This transdermal absorption is a positive feature, in my medical opinion. 

Here’s the rub: The majority of estrogen and progesterone (and testosterone) creams used in the U.S. are compounded and not of pharmaceutical grade. This means there are no uniform standards by which those creams are made or compounded, as there are for a pharma-grade product. It has nothing to do with whether the product is bioidentical or synthetic; it has to do with how the product is actually made. With compounded medications, a compounding pharmacist mixes up the product according to a “recipe.” Some compounding pharmacies in the U.S. are reputable and safe, but many are not. And it can be very difficult to distinguish between the two. 

It’s what I like to call the “lasagna analogy”: If I order lasagna in two restaurants, what comes out of those kitchens may be lasagna, but I have no idea what ingredients went into either lasagna or how each kitchen prepared that lasagna. Similarly, with compounded hormones, I have no way of knowing just how many milligrams of estrogen is actually in a particular cream. I also don't know what other ingredients are in that cream. By contrast, makers of pharmaceutical-grade products (those made in FDA-inspected and accredited manufacturing plants) have to comply with ingredient, purity, and accuracy standards in order to be licensed by the FDA. Because of this, a number of organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the North American Menopause Society (NAMS), recommend that FDA-approved products, such as the patch, be the standard for transdermal HRT.

Additionally, the absorption rate of a cream applied to the skin can be more variable than that of a pill/oral medication, because there are varying degrees of subcutaneous fat on women’s bodies (your forearm will be different than someone else's forearm, for example). The thickness of the epidermis (the outermost layer of skin) can vary as well. And even the actual application technique can affect absorption (if someone applies it onto wet skin, which results in the cream getting diluted or slipping off, or if the cream gets absorbed into clothing, etc.). 

In my practice, over nearly 20 years, I had very few patients express interest in transdermal creams, possibly for some of the reasons noted above. I did have many women prefer the profile of a hormonal patch, which we’ll discuss in future issues of TODAY’S AJENDA. If you decide to try a compounded hormonal cream: If you still have your uterus, you must take progesterone in some form if you are taking estrogen in a systemic form. Choose your compounding pharmacy carefully, and remember that the checks and balances offered by a pharmaceutical-grade product currently do not exist for compounded medications. 

SYMPTOM SOLUTIONS

Everything you need to know about ovarian cysts.

Here's something I've heard from patients literally thousands of times throughout my career as an OB-GYN: "I'm freaking out because I was told [usually by a radiologist or emergency medicine physician] that I have a cyst on one of my ovaries!" My response is always the same: “All cysts are not created equally. And ovaries make cysts for a living!” Here's the mini-med school on ovarian cysts, particularly for women in perimenopause and menopause.

A cyst is, in fact, the outcome of monthly ovulation. The process of ovulating (releasing an egg) is actually the rupturing of a tiny “cyst” or follicle. When that follicle doesn’t rupture and release its egg, it remains on the ovary and continues to grow. Ovarian cysts are common: According to the National Institutes of Health, 10 of every 100 women in the U.S. are estimated to have them. Most, however, are harmless; normally, we experience little or no discomfort. And most disappear without treatment within a few months; currently, just 8% of perimenopausal women who develop cysts will require medical treatment. Traditionally in gynecology, we don't even consider something a cyst until it’s larger than 2.5-3 cm. Sometimes cysts can become quite large and require surgical treatment, but usually this is when they are the size of oranges or grapefruits (larger than 8 cm or so).

Cysts can occur throughout a woman’s reproductive years and beyond. Let's look at the age groups separately: women younger than 50, then women over the age of 50.

Women under 50 (and remember that perimenopause can start for some women in their mid-30s) can develop ovarian cysts for many reasons: pregnancy, endometriosis, polycystic ovary syndrome (PCOS), dermoid cysts, or ovarian cancer, to name a few. If I did ultrasounds on every woman under the age of 50, the vast majority would find something a radiologist could easily describe as a cyst. Most of these would spontaneously resolve within 4-8 weeks; thus, gynecologists wouldn’t normally bat an eye at them. Here are the questions to keep in mind/ask your doctor if you’re ever diagnosed with a cyst:

• How large is the cyst in actual centimeters?

• Does it appear “simple or complex” on an ultrasound? These are features we look for to help us determine what kind of cyst it is.

• Does it have any features that might indicate malignancy? These include solid components, septations (thin bands of tissue), surface nodularity, and increased/abnormal blood flow.

• Is there an abnormal amount of “free fluid” in the pelvis? All pre-menopausal women have some degree of free fluid in the pelvis, but having a moderate or excessive amount is generally not normal.

• What follow-up is recommended? 

In women over 50, and especially women who have been in menopause for a while, the ovaries are generally NOT active enough to be making cysts anymore. Therefore, if a 58- or 68-year-old woman is told she has a cyst, in addition to asking the questions above, I also recommend blood tests to check for various tumor markers, along with a detailed history and physical exam. 

It’s important not to ignore a cyst if you’re a post-menopausal woman—because it could potentially be serious. While there is no accepted screening test for ovarian cancer, the CA-125 blood test can be elevated with some types of this disease. And that’s not the only marker that can be checked: There are several other tumor markers that indicate the presence of ovarian cancer. Ask about adding the following to a blood test panel: AFP, hCG, inhibin A and B, LDH, HE-4, CA 19-9, and CEA. Keep in mind that some of these values can be elevated even when no cancer is present, just as they might be normal when there IS cancer. Other conditions can cause some values to increase too, so correct interpretation of the blood tests is as important as the interpretation of the ultrasound.

If you are told you have a “cyst” that was found incidentally, don’t panic! Speak to your gynecologist about what the next steps are and how to interpret what was seen on ultrasound or CT scan. And be aware of the most common symptoms of ovarian cancer: pelvic pain, pressure or discomfort, bloating, increase in urination, early satiety (not feeling as hungry), or change in abdominal girth. If you notice these symptoms for more than 2 weeks and/or they feel different to you in any way from your previous experience, do not ignore them. See your gynecologist, who will likely order a pelvic ultrasound as a first step.

COMMUNITY

“Why am I getting acne at 40 years old?!?”

Just add braces, and we may as well be in middle school, hiding our faces again. Nobody liked it as a teenager, and we’re even less thrilled when it turns up during our menopausal years—no wonder its medical name is acne vulgaris! I asked our Core Expert, dermatologist Dr. Emily Wise, to explain what brings this adolescent scourge back and how best to treat acne-prone skin.

Acne in adult women is very common—in fact, I see it in my dermatology clinic multiple times a day, every day! While adolescents and teens typically experience breakouts across the forehead and down the mid-face (T-zone), acne in women tends to show up as more inflammatory, deep/cystic, and often tender pimples on the lower third of the face (including the chin, jawline, and neck).

The current thinking is that this acne is largely triggered by hormones. Many women feel their acne flares during periods and pregnancy, with certain types of birth control, and sometimes during menopause. For most women, this type of acne is not a marker of any systemic or concerning hormonal problem. Rather, normal levels of hormone stimulate the sebaceous glands to release sebum (an oil that resides in the glands), which promotes acne formation. If you have other symptoms that may indicate a systemic hormonal disturbance (for example, increased facial hair, deepening of the voice, or menstrual irregularities), you should talk to your doctor; you may require further evaluation and/or treatment.

Certain foods, such as dairy products and foods with a high glycemic index (which can spike blood sugar levels), have also been thought to increase acne formation. While this is considered when counseling patients, because acne in adult women is often strongly hormonally driven, you should speak with a dermatologist before making any drastic changes to your diet.

The most targeted treatment option is an oral medication called spironolactone. It has been used by dermatologists for years very safely but is still considered off-label. It works by reducing hormonal effects on the sebaceous glands and can often help even those with moderate to severe acne achieve clear or nearly clear skin in about 3-4 months’ time. There are also prescription cream regimens that usually contain a combination of antibiotic and retinoid agents, which may help reduce hormonally driven acne. But typically, these are not as effective as oral therapy, and some topicals may increase your risk of sun sensitivity. Other treatment options include certain types of laser and/or light therapy.

A word about pimples: To reduce the risk of scarring, it’s important to avoid picking or popping acne lesions. But even pimples that are not popped may leave scars or discoloration. Given this, and especially if you are using certain topicals, it’s important to use sunscreen to reduce the risk of long-term hyperpigmentation.

Bottom line: If you are experiencing acne as an adult, I strongly recommend you speak with a board-certified dermatologist, who can customize a treatment plan with medications and/or skin-care products that are best-suited for your specific type of acne. Early intervention will also help minimize the risk of permanent scarring.  

OUR CORE EXPERT

Emily M. Wise, MD is a board-certified dermatologist and founder of DermWellesley in Wellesley, Massachusetts, where she practices medical and cosmetic dermatology. She lectures regularly about acne management and also has extensive experience with laser therapy and neurotoxins such as Botox and Dysport. Dr. Wise is a member of both the Dean’s Advisory Board at the Boston University School of Medicine and the Medical Advisory Board for IMPACT Melanoma. @dermwellesley

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ABOUT DR. JEN

In her roles as chief medical correspondent for ABC News and on-air cohost of “GMA3: What You Need to Know,” Dr. Jennifer Ashton—”Dr. Jen”—shares the latest health news and information with millions of viewers nationwide. As an OB-GYN, nutritionist, and board-certified obesity medicine specialist, she is passionate about promoting optimal health for “the whole woman.” She has written several books, including the best-selling The Self-Care Solution: A Year of Becoming Happier, Healthier & Fitter—One Month at a Time. And she has gone through menopause…

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